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Metacarpal shaft fractures: The effect of shortening on the extensor tendon mechanism
Metacarpal Shaft Fractures: The Effect of Shortening on the Extensor Tendon Mechanism Robert J. Strauch, MD, Melvin P. Rosenwasser, MD, New York, NY, John G. Lunt, MD, Danbury, CT Spiral and oblique metacarpal shaft fractures frequently develop shortening through the fracture site. The acceptable amount of fracture shortening has not been well established. The goal of this study was to elucidate the acceptable limits of metacarpal shaft fracture shortening in a cadaver model by assessing the magnitude of the metacarpophalangeal (MCP) joint extensor lag produced. Nine fresh-frozen cadaver hands were used to create a metacarpal shaft fracture model in the second and fifth metacarpal bones. Sequential shortening up to 10 mm in 2-mm increments was performed. The results revealed an average of 7 ~ of extensor lag at the MCP joint produced for every 2 mm of metacarpal shortening. The capacity of the MCP joint for active hyperextension may compensate for the extensor lag produced by metacarpal shortening in the clinical setting. (J Hand Surg 1998;23A:519-523. Copyright 9 1998 by the American Society for Surgery of the Hand.)
Metacarpal fractures are a m o n g the more c o m m o n types of hand injury. In a review of over 1,500 hand fractures, Dobyns et al. 1 found that 22% involved the metacarpals. Kelsey et al. 2 reported that an estimated 15% of hand injuries in 1975 alone were metacarpal fractures resulting in 1.1 million days of disability and hundreds of millions of dollars in cost to industry. Metacarpal shaft fractures can deform in 3 ways: by rotation, angulation, or longitudinal shortening. Some guidelines are available concerning the amount of acceptable rotation or angulation at the fracture site, 3-5 but the limits of shortening appear to be more controversial. Many studies of metacarpal fractures
From the Department of Orthopaedic Surgery, Columbia-Presbyterian Medical Center, New York, NY. Received for publication March 13, 1996; accepted for publication December 19, 1997. No benefits in any form have been received or will be received from a commercialparty related directly or indirectly to the subject of this article. Reprint requests: RobertJ. Strauch, MD, Departmentof Orthopaedic Surgery, Columbia-PresbyterianMedical Center, 161 Fort Washington Ave, New York, NY 10032. Copyright 9 1998 by the AmericanSocietyfor Surgeryof the Hand. 0363-5023/98/23A03-001953.00/0
have been reported, but all suffer from 1 of 3 problems in discussing acceptable limits of shortening at the fractures: shortening is not presented as a concern, 6-12 shortening is mentioned but no data are presented, 13-18 or the rationale for determining the amount of acceptable shortening allowable is not discussed.3 5,15,19-25 The acceptable limits of shortening presented in the literature range f r o m none to 6 m m or more; similarly, the justifications for the given amounts vary. Jupiter and Belsky 5 postulate that an intrinsic/extrinsic imbalance will occur with more than 3 nun of shortening. Burkhalter 21 stated that there m a y be a transient metacarpophalangeal (MCP) joint extensor lag with large amounts of shortening, but no long-term functional loss will result. Green and Rowland 3 supplied no data to support a stated amount of 5 m m for acceptable shortening. Freeland et al. 23 tolerated 3 to 4 m m of shortening, but stated that greater amounts are usually associated with rotation or angulation. L u m p l e s c h et al. 24 found that up to 6 m m of shortening was consistent with good hand function. Shortening of metacarpal shaft fractures m a y produce a minor cosmetic deformity: the loss of the normal prominence of the metacarpal head. s Func-
The Journal of Hand Surgery 519
520 Strauch et al. / Metacarpal Shortening tional deficits produced by metacarpal shortening may result from effects on the flexors, the intrinsics, or the extensor tendons. Relative lengthening of individual flexor tendons, as in an excessively long free tendon graft, may produce "paradoxical proximal interphalangeal joint extension" secondary to the lumbrical becoming tight before the long flexor. With metacarpal shortening, both the flexor and lumbrical will be equally relatively lengthened; therefore, this phenomenon should not be a problem, although there is a theoretical loss of full strength of contraction. Similarly, the interossei are unlikely to be affected by metacarpal shaft fracture shortening since sufficient distal fragment length (from which the muscle originates) should be present to avoid noteworthy muscle-tendon length discrepancies; both the origin and insertion will shift proximally. The common finger extensors, however, will undergo a relative lengthening that may lead to an extensor lag at the MCP joint. 21 The goal of this study is to assess the effect of metacarpal fracture shortening on the amount of extensor lag produced at the MCP joint.
Materials and Methods In the first part of the study, 4 flesh-frozen cadaver hands free of bony defects were allowed to warm to room temperature. The second and fifth metacarpal shafts were exposed by subperiosteal dissection. Using a sagittal saw, a short oblique osteotomy was created, the fragments were axially manually compressed, and the amount of maximal shortening at the fracture site was measured. In the second part of the study, 9 separate fleshfrozen adult cadaver upper extremities were allowed to warm to room temperature. The dorsal skin and subcutaneous tissues were removed, preserving the entire extensor mechanism. The long extensor tendons (including the proprii) were sutured together at constant tension and attached proximally to a 1.5-kg free weight designed to produce maximum extension at the MCP joint. The wrist was held in neutral with a Synthes AO/ASIF small external fixator (Monument, CO). A metacarpal shaft fracture model was then created in the second and fifth metacarpal shafts by resecting a 15-mm segment of the midportion of the metacarpal and maintaining anatomic length with a separate small AO/ASIF external fixator with 2.5-mm pins proximal and distal to the intercalary resection. Shortening the metacarpal exter-
Figure 1. Experimental design with fracture models of the second and fifth metacarpals to allow metacarpal shortening without rotation or angulation.
nal fixator then produced measurable axial shortening. The index and small metacarpals were chosen for this study because their peripheral location allowed creation of the gap as well as placement of the external fixator without violating the extensor apparatus (Fig. 1). The metacarpal fixators were then shortened separately in 2-mm increments up to 10 mm. Baseline measurements were made of the MCP joint angle followed by measurements after each increment of shortening. All MCP joints had full passive range of motion, and there were no pre-existing bony or tendinous anomalies.
The Journal of Hand Surgery / Vol. 23A No. 3 May 1998
521
-50 -40 -30
O9 0") d) "0 D) c-
<
-2O -10 1 0
. . . . .
_
10
_
_
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20
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9
0
2
Amount of
4
6
8
~
~
1||lnnms
l w ~ , m
10
Metacarpal Shortening (millimeters)
Figure 2. Second metacarpal shortening versus metacarpophalangeal joint angle.
Results In the first part of the study, the average maximum shortening produced at the short oblique fracture model site was 5 mm (range, 4 - 6 mm). The obstacles to further shortening appeared to be the deep transverse intermetacarpal ligament and the fracture ends sliding into the adjacent metacarpal bones and interosseous muscles. In the second part of the study, removing a segment of metacarpal shaft and applying compression with the external fixator allowed shortening to the full 10 mm. For each 2-mm increment of metacarpal shortening, an average extensor lag of 7 ~ was produced at the MCP joint. A total of 35 ~ of extensor lag resulted from the maximum shortening of 10 mm. There was no significant difference between the second and fifth metacarpal fracture models. On average, the relationship of amount of shortening to extensor lag was linear. Seven of the 9 hands had an average of 20 ~ of hyperextension present at the MCP joint as a baseline value (Figs. 2 and 3).
Discussion In the absence of rotational or angulatory deformity of metacarpal shaft fractures, the main clinical
concern is of residual functional impairment due to shortening. The cosmetic deformity produced by a depressed metacarpal head is usually not a problem, provided that the patient understands from the outset that the appearance will be permanent. On theoretical grounds, we chose to study the extensor lag produced at the MCP joint as the principal deficit that might result from shortening of spiral or oblique metacarpal shaft fractures. Most clinical series of metacarpal fractures report shortening of less than 6 mm, which probably approximates the maximum amount permitted by the tethering effect of the deep transverse intermetacarpal ligament connecting the fractured bone to the adjacent intact metacarpal. In this study, 6 mm of shortening produced a 21 ~ extensor lag at the MCP joint, without consideration for future muscle-tendon unit dynamic rebalancing. Since most of the MCP joints exhibited hyperextension to 20 ~ this amount of extensor lag would still allow MCP joint extension to near-neutral. Low et al. 26 performed a recent study in which they assessed the ratio of extensor and flexor forces required to produce full MCP joint extension with intact versus angulated or shortened metacarpal fracture models. These investigators found that with
522
Strauch et al. / Metacarpal Shortening
_30iiiiii!iiiiiliiiiiiiliiiiiiii!iiJiili il!i!iiiiii!iiiiiiiiiiiili!!!iii!iiii il!iiiiiilii!i!iiiiiii!ii -20 (3") "0
"-" c-
<
-10 1 0
..... _ ~
10
4 m 5m
20 30
7~
w
8HH||gJ
40 0
9 ~ m
2
Amount of
4
6
8
10
Metacarpal Shortening (millimeters)
Figure 3. Fifth metacarpal shortening versus metacarpophalangeal joint angle.
metacarpal shortening beyond 3 mm, a statistically significant decrease in extension and flexion "ratios" resulted. Shortening of 6 mm produced a 20% decrease in the "mean extension force ratio." Low et al. did not mention whether an extension lag was produced as a result of this loss of extensor force. In our study, force application was kept constant, and the variables included shortening and joint angle. In this study, the common extensors and proprii were placed under common tension. A limitation of this study, therefore, is that the measured extensor lag might be different if the proprii were separated from the common extensors. In the clinical setting, due to the dual-tendon structure of the index and small fingers at the MCP joint, it is possible that a lessor extensor lag would be observed than at the middle or ring fingers for a given amount of metacarpal shortening. Tethering the extensors and proprii together, as was done in this study, therefore creates a "worst case scenario" for the maximum extensor lag that might be observed in all 4 fingers. This study did not assess the effect of metacarpal shaft shortening on the flexor tendon mechanism. Metacarpal shortening should relatively lengthen all flexors to the involved digit. The theroretical effect
would be to reduce flexion power in the digit. Since the superficial flexor, deep flexor, and lumbrical mechanisms would all be equally relatively lengthened, problems such as paradoxical extension, which is seen with excessively long profundus grafts, or the quadriga effect, which is seen with fight profundii, should not occur. Future studies concerning alterations of flexor force produced by metacarpal shortening would help elucidate whether significant changes are produced. Our current clinical approach to spiral or long oblique metacarpal shaft fractures with shortening is to obtain a reduction of rotational or angulatory deformities; this is accomplished with a local anesthetic block, although usually no reduction is required. A functional cast is applied, and the involved finger is assessed for rotational alignment and active flexion/extension at the MCP joint. Full extension is usually possible, and cast treatment is continued. Rotational deformities are corrected by buddy-taping the fingers and allowing finger motion. If adequate MCP joint extension is not achieved despite adequate anesthesia, consideration should be given to surgical restoration of the metacarpal length.
The Journal of Hand Surgery / Vol. 23A No. 3 May 1998
References 1. Dobyns JH, Linscheid RL, Cooney WP III. Fractures and dislocations of the wrist and hand, then and now. J Hand Surg 1983;8:687-690. 2. Kelsey JL, Pastides H, Kreiger N. Upper extremity disorders: a survey of their frequency and cost in the United States. St Louis: CV Mosby, 1980. 3. Green DP, Rowland SA. Fractures and dislocations in the hand. In: Rockwood CA Jr, Green DP, Bucholz RW, eds. Fractures in adults. 3rd ed. New York: JB Lippincott, 1982:760-774. 4. Stem PJ. Fractures of the metacarpals and phalanges. In: Green DP, ed. Operative hand surgery. Vol. 1.3rd ed. New York: Churchill Livingstone, 1991:701-704. 5. Jupiter JE, Belsky MR. Fractures and dislocations of the hand. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal trauma. Vol. 2. Philadelphia: WB Saunders, 1992:925-959. 6. Jahss SA. Fractures of the metacarpals: a new method of reduction and immobilization. J Bone Joint Surg 1938;20: 178-186. 7. Meyer VE, Chiu DTW, Beasley RW. The place of intemal skeletal fixation in surgery of the hand. Clin Plast Surg 1981;8:51-64. 8. Freeland AE, Jabaley ME, Burkhalter WE, Chaves AMV. Delayed primary bone grafting in the hand and wrist after traumatic bone loss. J Hand Surg 1984;9A:22-27. 9. Greene TL, Noellert RC, Belsole RJ. Treatment of unstable metacarpal and phalangeal fractures with tension band wiring techniques. Clin Orthop 1987;214:78-84. 10. Lewis RC, Nordyke M, Duncan K. Expandable intramedullary device for treatment of fractures in the hand. Clin Orthop 1987;214:85-92. 11. Swanson AB. Fractures involving the digits of the hand. Orthop Clin North Am 1970;1:261-274. 12. Justis EJ. Fractures, dislocations, and ligamentous injuries. In: Crenshaw AH, ed. Campbell's operative orthopaedics. Vol. 5. 8th ed. St Louis: Mosby-Year Book, 1992:3078-3086.
523
13. Hastings H II. Unstable metacarpal and phalangeal fracture treatment with screws and plates. Clin Orthop 1987;214: 37-52. 14. Beasley RW. Skeletal injuries. In: Hand injuries. Philadelphia: WB Saunders, 1981:208-210. 15. Gropper PT, Bowen V. Cerclage wiring of metacarpal fractures. Clin Orthop 1984;188:203-207. 16. Edwards GS Jr, O'Brien ET, Heckman MM. Retrograde cross-pinning of transverse metacarpal and phalangeal fractures. Hand 1982;14:141-148. 17. Jupiter JE, Silver MA. Fractures of the metacarpals and phalanges. In: Chapman MW, ed. Operative orthopaedics. Vol. 2. Philadelphia: JB Lippincott, 1988:1235-1241. 18. Barton NJ. Fractures and joint injuries of the hand. In: Wilson FN, ed. Watson-Jones fractures and joint injuries. Vol. 2. 6th ed. Edinburgh: Churchill Livingstone, 1982: 760 -774. 19. Workman CE. Metacarpal fractures. Mo Med 1964;61: 687-696. 20. Butt WD. Fractures of the hand. III. Treatment and results. Can Med Assoc J 1962;86:815-822. 21. Burkhalter WE. Hand fractures. In: Greene WB, ed. Instructional course lectures. Vol. 39. Chicago: American Academy of Orthopaedic Surgeons, 1990:249-253. 22. Burkhalter WE, Reyes FA. Closed treatment of fractures of the hand. Bull Hosp Joint Dis 1984;44:145-162. 23. Freeland AE, Jabaley ME, Hughes JL. Stable fixation of the hand and wrist. New York: Springer-Verlag, 1986. 24. Lumplesch R, Zilch H, Friedebold G. Frakturen der Mittelhandknochen II-V--Konservative und operative Behandlung. Unfallchirurg 1985;11:115-118. 25. Littler JW. Metacarpal reconstruction. J Bone Joint Surg 1947;29:723-737. 26. Low CK, Wong HC, Low YP, Wong HP. A cadaver study of the effects of dorsal angulation and shortening of the metacarpal shaft on the extension and flexion force ratios of the index and little fingers. J Hand Surg 1995;20B:609613.
Metacarpal fractures are a m o n g the more c o m m o n types of hand injury. In a review of over 1,500 hand fractures, Dobyns et al. 1 found that 22% involved the metacarpals. Kelsey et al. 2 reported that an estimated 15% of hand injuries in 1975 alone were metacarpal fractures resulting in 1.1 million days of disability and hundreds of millions of dollars in cost to industry. Metacarpal shaft fractures can deform in 3 ways: by rotation, angulation, or longitudinal shortening. Some guidelines are available concerning the amount of acceptable rotation or angulation at the fracture site, 3-5 but the limits of shortening appear to be more controversial. Many studies of metacarpal fractures
From the Department of Orthopaedic Surgery, Columbia-Presbyterian Medical Center, New York, NY. Received for publication March 13, 1996; accepted for publication December 19, 1997. No benefits in any form have been received or will be received from a commercialparty related directly or indirectly to the subject of this article. Reprint requests: RobertJ. Strauch, MD, Departmentof Orthopaedic Surgery, Columbia-PresbyterianMedical Center, 161 Fort Washington Ave, New York, NY 10032. Copyright 9 1998 by the AmericanSocietyfor Surgeryof the Hand. 0363-5023/98/23A03-001953.00/0
have been reported, but all suffer from 1 of 3 problems in discussing acceptable limits of shortening at the fractures: shortening is not presented as a concern, 6-12 shortening is mentioned but no data are presented, 13-18 or the rationale for determining the amount of acceptable shortening allowable is not discussed.3 5,15,19-25 The acceptable limits of shortening presented in the literature range f r o m none to 6 m m or more; similarly, the justifications for the given amounts vary. Jupiter and Belsky 5 postulate that an intrinsic/extrinsic imbalance will occur with more than 3 nun of shortening. Burkhalter 21 stated that there m a y be a transient metacarpophalangeal (MCP) joint extensor lag with large amounts of shortening, but no long-term functional loss will result. Green and Rowland 3 supplied no data to support a stated amount of 5 m m for acceptable shortening. Freeland et al. 23 tolerated 3 to 4 m m of shortening, but stated that greater amounts are usually associated with rotation or angulation. L u m p l e s c h et al. 24 found that up to 6 m m of shortening was consistent with good hand function. Shortening of metacarpal shaft fractures m a y produce a minor cosmetic deformity: the loss of the normal prominence of the metacarpal head. s Func-
The Journal of Hand Surgery 519
520 Strauch et al. / Metacarpal Shortening tional deficits produced by metacarpal shortening may result from effects on the flexors, the intrinsics, or the extensor tendons. Relative lengthening of individual flexor tendons, as in an excessively long free tendon graft, may produce "paradoxical proximal interphalangeal joint extension" secondary to the lumbrical becoming tight before the long flexor. With metacarpal shortening, both the flexor and lumbrical will be equally relatively lengthened; therefore, this phenomenon should not be a problem, although there is a theoretical loss of full strength of contraction. Similarly, the interossei are unlikely to be affected by metacarpal shaft fracture shortening since sufficient distal fragment length (from which the muscle originates) should be present to avoid noteworthy muscle-tendon length discrepancies; both the origin and insertion will shift proximally. The common finger extensors, however, will undergo a relative lengthening that may lead to an extensor lag at the MCP joint. 21 The goal of this study is to assess the effect of metacarpal fracture shortening on the amount of extensor lag produced at the MCP joint.
Materials and Methods In the first part of the study, 4 flesh-frozen cadaver hands free of bony defects were allowed to warm to room temperature. The second and fifth metacarpal shafts were exposed by subperiosteal dissection. Using a sagittal saw, a short oblique osteotomy was created, the fragments were axially manually compressed, and the amount of maximal shortening at the fracture site was measured. In the second part of the study, 9 separate fleshfrozen adult cadaver upper extremities were allowed to warm to room temperature. The dorsal skin and subcutaneous tissues were removed, preserving the entire extensor mechanism. The long extensor tendons (including the proprii) were sutured together at constant tension and attached proximally to a 1.5-kg free weight designed to produce maximum extension at the MCP joint. The wrist was held in neutral with a Synthes AO/ASIF small external fixator (Monument, CO). A metacarpal shaft fracture model was then created in the second and fifth metacarpal shafts by resecting a 15-mm segment of the midportion of the metacarpal and maintaining anatomic length with a separate small AO/ASIF external fixator with 2.5-mm pins proximal and distal to the intercalary resection. Shortening the metacarpal exter-
Figure 1. Experimental design with fracture models of the second and fifth metacarpals to allow metacarpal shortening without rotation or angulation.
nal fixator then produced measurable axial shortening. The index and small metacarpals were chosen for this study because their peripheral location allowed creation of the gap as well as placement of the external fixator without violating the extensor apparatus (Fig. 1). The metacarpal fixators were then shortened separately in 2-mm increments up to 10 mm. Baseline measurements were made of the MCP joint angle followed by measurements after each increment of shortening. All MCP joints had full passive range of motion, and there were no pre-existing bony or tendinous anomalies.
The Journal of Hand Surgery / Vol. 23A No. 3 May 1998
521
-50 -40 -30
O9 0") d) "0 D) c-
<
-2O -10 1 0
. . . . .
_
10
_
_
4----5 ~
20
7 8
30 40
9
0
2
Amount of
4
6
8
~
~
1||lnnms
l w ~ , m
10
Metacarpal Shortening (millimeters)
Figure 2. Second metacarpal shortening versus metacarpophalangeal joint angle.
Results In the first part of the study, the average maximum shortening produced at the short oblique fracture model site was 5 mm (range, 4 - 6 mm). The obstacles to further shortening appeared to be the deep transverse intermetacarpal ligament and the fracture ends sliding into the adjacent metacarpal bones and interosseous muscles. In the second part of the study, removing a segment of metacarpal shaft and applying compression with the external fixator allowed shortening to the full 10 mm. For each 2-mm increment of metacarpal shortening, an average extensor lag of 7 ~ was produced at the MCP joint. A total of 35 ~ of extensor lag resulted from the maximum shortening of 10 mm. There was no significant difference between the second and fifth metacarpal fracture models. On average, the relationship of amount of shortening to extensor lag was linear. Seven of the 9 hands had an average of 20 ~ of hyperextension present at the MCP joint as a baseline value (Figs. 2 and 3).
Discussion In the absence of rotational or angulatory deformity of metacarpal shaft fractures, the main clinical
concern is of residual functional impairment due to shortening. The cosmetic deformity produced by a depressed metacarpal head is usually not a problem, provided that the patient understands from the outset that the appearance will be permanent. On theoretical grounds, we chose to study the extensor lag produced at the MCP joint as the principal deficit that might result from shortening of spiral or oblique metacarpal shaft fractures. Most clinical series of metacarpal fractures report shortening of less than 6 mm, which probably approximates the maximum amount permitted by the tethering effect of the deep transverse intermetacarpal ligament connecting the fractured bone to the adjacent intact metacarpal. In this study, 6 mm of shortening produced a 21 ~ extensor lag at the MCP joint, without consideration for future muscle-tendon unit dynamic rebalancing. Since most of the MCP joints exhibited hyperextension to 20 ~ this amount of extensor lag would still allow MCP joint extension to near-neutral. Low et al. 26 performed a recent study in which they assessed the ratio of extensor and flexor forces required to produce full MCP joint extension with intact versus angulated or shortened metacarpal fracture models. These investigators found that with
522
Strauch et al. / Metacarpal Shortening
_30iiiiii!iiiiiliiiiiiiliiiiiiii!iiJiili il!i!iiiiii!iiiiiiiiiiiili!!!iii!iiii il!iiiiiilii!i!iiiiiii!ii -20 (3") "0
"-" c-
<
-10 1 0
..... _ ~
10
4 m 5m
20 30
7~
w
8HH||gJ
40 0
9 ~ m
2
Amount of
4
6
8
10
Metacarpal Shortening (millimeters)
Figure 3. Fifth metacarpal shortening versus metacarpophalangeal joint angle.
metacarpal shortening beyond 3 mm, a statistically significant decrease in extension and flexion "ratios" resulted. Shortening of 6 mm produced a 20% decrease in the "mean extension force ratio." Low et al. did not mention whether an extension lag was produced as a result of this loss of extensor force. In our study, force application was kept constant, and the variables included shortening and joint angle. In this study, the common extensors and proprii were placed under common tension. A limitation of this study, therefore, is that the measured extensor lag might be different if the proprii were separated from the common extensors. In the clinical setting, due to the dual-tendon structure of the index and small fingers at the MCP joint, it is possible that a lessor extensor lag would be observed than at the middle or ring fingers for a given amount of metacarpal shortening. Tethering the extensors and proprii together, as was done in this study, therefore creates a "worst case scenario" for the maximum extensor lag that might be observed in all 4 fingers. This study did not assess the effect of metacarpal shaft shortening on the flexor tendon mechanism. Metacarpal shortening should relatively lengthen all flexors to the involved digit. The theroretical effect
would be to reduce flexion power in the digit. Since the superficial flexor, deep flexor, and lumbrical mechanisms would all be equally relatively lengthened, problems such as paradoxical extension, which is seen with excessively long profundus grafts, or the quadriga effect, which is seen with fight profundii, should not occur. Future studies concerning alterations of flexor force produced by metacarpal shortening would help elucidate whether significant changes are produced. Our current clinical approach to spiral or long oblique metacarpal shaft fractures with shortening is to obtain a reduction of rotational or angulatory deformities; this is accomplished with a local anesthetic block, although usually no reduction is required. A functional cast is applied, and the involved finger is assessed for rotational alignment and active flexion/extension at the MCP joint. Full extension is usually possible, and cast treatment is continued. Rotational deformities are corrected by buddy-taping the fingers and allowing finger motion. If adequate MCP joint extension is not achieved despite adequate anesthesia, consideration should be given to surgical restoration of the metacarpal length.
The Journal of Hand Surgery / Vol. 23A No. 3 May 1998
References 1. Dobyns JH, Linscheid RL, Cooney WP III. Fractures and dislocations of the wrist and hand, then and now. J Hand Surg 1983;8:687-690. 2. Kelsey JL, Pastides H, Kreiger N. Upper extremity disorders: a survey of their frequency and cost in the United States. St Louis: CV Mosby, 1980. 3. Green DP, Rowland SA. Fractures and dislocations in the hand. In: Rockwood CA Jr, Green DP, Bucholz RW, eds. Fractures in adults. 3rd ed. New York: JB Lippincott, 1982:760-774. 4. Stem PJ. Fractures of the metacarpals and phalanges. In: Green DP, ed. Operative hand surgery. Vol. 1.3rd ed. New York: Churchill Livingstone, 1991:701-704. 5. Jupiter JE, Belsky MR. Fractures and dislocations of the hand. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal trauma. Vol. 2. Philadelphia: WB Saunders, 1992:925-959. 6. Jahss SA. Fractures of the metacarpals: a new method of reduction and immobilization. J Bone Joint Surg 1938;20: 178-186. 7. Meyer VE, Chiu DTW, Beasley RW. The place of intemal skeletal fixation in surgery of the hand. Clin Plast Surg 1981;8:51-64. 8. Freeland AE, Jabaley ME, Burkhalter WE, Chaves AMV. Delayed primary bone grafting in the hand and wrist after traumatic bone loss. J Hand Surg 1984;9A:22-27. 9. Greene TL, Noellert RC, Belsole RJ. Treatment of unstable metacarpal and phalangeal fractures with tension band wiring techniques. Clin Orthop 1987;214:78-84. 10. Lewis RC, Nordyke M, Duncan K. Expandable intramedullary device for treatment of fractures in the hand. Clin Orthop 1987;214:85-92. 11. Swanson AB. Fractures involving the digits of the hand. Orthop Clin North Am 1970;1:261-274. 12. Justis EJ. Fractures, dislocations, and ligamentous injuries. In: Crenshaw AH, ed. Campbell's operative orthopaedics. Vol. 5. 8th ed. St Louis: Mosby-Year Book, 1992:3078-3086.
523
13. Hastings H II. Unstable metacarpal and phalangeal fracture treatment with screws and plates. Clin Orthop 1987;214: 37-52. 14. Beasley RW. Skeletal injuries. In: Hand injuries. Philadelphia: WB Saunders, 1981:208-210. 15. Gropper PT, Bowen V. Cerclage wiring of metacarpal fractures. Clin Orthop 1984;188:203-207. 16. Edwards GS Jr, O'Brien ET, Heckman MM. Retrograde cross-pinning of transverse metacarpal and phalangeal fractures. Hand 1982;14:141-148. 17. Jupiter JE, Silver MA. Fractures of the metacarpals and phalanges. In: Chapman MW, ed. Operative orthopaedics. Vol. 2. Philadelphia: JB Lippincott, 1988:1235-1241. 18. Barton NJ. Fractures and joint injuries of the hand. In: Wilson FN, ed. Watson-Jones fractures and joint injuries. Vol. 2. 6th ed. Edinburgh: Churchill Livingstone, 1982: 760 -774. 19. Workman CE. Metacarpal fractures. Mo Med 1964;61: 687-696. 20. Butt WD. Fractures of the hand. III. Treatment and results. Can Med Assoc J 1962;86:815-822. 21. Burkhalter WE. Hand fractures. In: Greene WB, ed. Instructional course lectures. Vol. 39. Chicago: American Academy of Orthopaedic Surgeons, 1990:249-253. 22. Burkhalter WE, Reyes FA. Closed treatment of fractures of the hand. Bull Hosp Joint Dis 1984;44:145-162. 23. Freeland AE, Jabaley ME, Hughes JL. Stable fixation of the hand and wrist. New York: Springer-Verlag, 1986. 24. Lumplesch R, Zilch H, Friedebold G. Frakturen der Mittelhandknochen II-V--Konservative und operative Behandlung. Unfallchirurg 1985;11:115-118. 25. Littler JW. Metacarpal reconstruction. J Bone Joint Surg 1947;29:723-737. 26. Low CK, Wong HC, Low YP, Wong HP. A cadaver study of the effects of dorsal angulation and shortening of the metacarpal shaft on the extension and flexion force ratios of the index and little fingers. J Hand Surg 1995;20B:609613.